Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men

Abstract

Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term.

Phalloplasty: understanding the chaos

“…However, due to anecdotal reports of urinary leakage and chronic accumulation in the vaginectomy cavity, which can require complex, secondary correction, some centers opt to perform vaginectomy at the time of hysterectomy and salpingo-oophorectomy [17,18] . Still, many high-volume centers prefer to perform vaginectomy at the time of pars fixa construction to allow the use of vascularized anterior vaginal myomucosal flaps to create a portion of the pars fixa urethra, hypothesizing that this may reduce the incidence of urinary strictures and fistulas [15,[19][20][21] . Note that although pars fixa construction has been described in patients who choose not to undergo vaginectomy, the significant risk profile for urethral complications with this approach leads most centers, current authors included, to advise against it.…”

“…That said, the nearly universal strategy is to use adjacent tissues, sometimes augmented with skin or buccal mucosal grafts, to construct a hairless, epithelial-lined tube from the location of the female urethral orifice to the base of the neophallus. The variations in specific techniques include (1) the degree of clitoral chordee release and resection of clitoral skin performed when repositioning the clitoral body [38,[59][60][61] ; (2) the timing of vaginectomy and the use (or not) of an anterior vaginal myomucosal turnover flap to augment the proximal pars fixa [20,21,62] ; (3) the use (or not) of skin or buccal mucosal grafts to form the dorsal "floor" of the pars fixa [61][62][63][64][65] ; (4) the specifics of labia minora pedicled flaps to construct the ventral "roof " of the pars fixa [60][61][62][63][64][65] ; (5) the timing of pars fixa construction (discussed below); and (6) the use (or not) of a pedicled gracilis muscle or other vascularized flap to augment healing of the multiple anastomotic suture lines necessary [66,67] . These variations have been employed in virtually every combination at various centers.…”

“…The second strategy is to perform a staged urethral fabrication using skin, vaginal mucosal, buccal mucosal or even uterine or colonic grafts [21,73,74] . This strategy has been employed in two ways.…”

“…Although a few centers use osteocutaneous flaps or place cartilage grafts primarily at the time of phallic construction [21,74] , for most patients, the ability to achieve penile rigidity sufficient for penetrative intercourse will rely on the placement of an erectile prosthesis. Despite enthusiastic demand from some patients and short-term data indicating efficacy, considerable variation in philosophy and the technical specifics regarding erectile prostheses are driven by high rates of eventual prosthetic infection and/or extrusion and of prosthesis malfunction [76] .…”

Piloting a Genital Affirmation Surgical Priorities Scale for Trans Masculine Patients

“…Extending the urethra to the tip of the neophallus gives patients the ability to urinate while standing. 8,9…”